A list of the most recent deficiencies for Briarfield Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-04 | 2023-02-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-19 | 2023-02-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-04 | 2023-02-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-23 | 2022-07-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-23 | 2022-07-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-06-23 | 2022-07-21 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-23 | 2022-07-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-07-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-23 | 2022-07-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-23 | 2022-07-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-23 | 2022-07-21 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-23 | 2022-07-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-23 | 2022-07-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-07-21 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-13 | 2022-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-13 | 2022-07-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-13 | 2022-07-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-16 | 2021-12-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-23 | 2021-07-05 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-06-23 | 2021-07-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-15 | 2019-08-29 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-07-18 | 2019-08-15 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-07-18 | 2019-08-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-18 | 2019-08-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-18 | 2019-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-18 | 2019-08-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-18 | 2019-08-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-18 | 2019-08-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-07-18 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-08-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-15 | 2019-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-15 | 2019-08-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-07-15 | 2019-08-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-06-04 | 2018-07-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-06-07 | 2018-06-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-06-07 | 2018-06-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-06-07 | 2018-06-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-06-07 | 2018-06-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-06-07 | 2018-06-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-07 | 2018-06-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-06-07 | 2018-06-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-06-07 | 2018-06-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-07 | 2018-06-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-07 | 2018-06-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-06-07 | 2018-06-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-06-04 | 2018-06-27 | N |
| Use approved construction type or materials. | Fire Safety | 2018-06-04 | 2018-06-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-04 | 2018-06-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-06-04 | 2018-06-27 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-06-04 | 2018-06-27 | N |
